Fee-splitting, or the act of receiving payment for referring a patient, has been a hotly debated topic in dermatology and in medicine in general. Specific to dermatology, a debate has grown over the ethics and legality of negotiating a discount on pathology services. If you have a pathologist or dermatopathologist review a patient’s slides, should you make money on a pathologist’s services? Or, are you simply referring the patient and should you, therefore, let the pathologist bill the patient directly? Two dermatologists take sides on this controversial issue.
Point
By Gary Goldenberg, M.D.
The Wall Street Journal (WSJ) recently ran a front-page article outlining a practice of fee-splitting, the term used to define the practice of physicians being paid for referring a patient to another physician or for a specific treatment. This practice is commonly used by dermatologists to increase profits and by pathologists to increase caseload and therefore, increase profit.1 Since the article emphasized this issue, a debate between pathologists, dermatologists and dermatopathologists has ensued.
The Journal of the American Academy of Dermatology recently published several editorials from some of the most well known and respected dermatologists and dermatopathologists in the field that outlined different points of view regarding this issue, as well as other related topics.2-5
I will review the above issues
and show the following:
1. Fee splitting is wrong, if not from the legal point of view (at least not in every state and not yet), certainly form an ethical point of view.
2. Dermatologists should be able to continue to “read out” their own slides, even if just on the “easy” cases.
3. Legal action should not be required in this case, since we should be able to police ourselves.
Why Fee-Splitting is Wrong
Let’s examine the following scenario. In “Small Town, USA” there is a large primary care group that refers its patients to two dermatology practices in town. What if one of the dermatology groups approached the primary care group with the following proposition: Send us all your dermatology cases for a per case flat fee and keep the insurance reimbursement difference as profit? (Of course, Medicare patients cannot be included in this deal since that would be illegal.)
Not only is there now financial incentive for the primary care group to refer all of its patients to the one dermatology practice, they will also directly profit from the labor of other physicians.
Aren’t there already enough malpractice attorneys who profit from our work? Also, will the other dermatology practice in this small town be able to survive?
I believe fee-splitting is morally wrong, not to mention that it may be in the grey area of the law. All billing is done by Medicare standards, so why not this? If Medicare continues to make fee-splitting illegal, it should also be illegal for all other insurance carriers.
Reading Our Own Slides
Now let’s tackle the issue of whether we should be able to read our own slides. The answer is yes, and here’s why.
First, some would argue that dermatologists do not have enough training to perform this task. This is simply not true. Feldman and colleagues showed that dermatology residents complete more hours of dermatopathology training than pathology residents and that there is more dermatopathology in dermatology literature than in pathology literature.6
In that case, if general pathologists are allowed to read out dermatology cases, so should dermatologists. Some have also argued that dermatologists only read out “easy” cases and send the more “difficult” cases to dermatopathologists for consultation. I argue that general pathologists do the same thing.
Should general pathologists not be allowed to read out dermatology cases? Are there enough board certified dermatopathologists to handle the growing load of skin biopsy specimens? The answer to both questions is probably no.
Focusing on Our Patients
Do we need more government or medical board regulations to tell us how to best treat our patients? The answer is a definite no. Furthermore, with 800,000 attorneys in this country, our legal system already provides enough disincentive for us not to perform any services with which we are uncomfortable. We also cannot forget to do what’s best for our patients. I am sure that most dermatology residents are very comfortable recognizing basal cell carcinomas, but I doubt that anyone would make a diagnosis of a melanoma without being a board certified dermatopathologist or consulting with a dermatopathologist.
Instead of focusing on differences of opinion, we need to concentrate on more pressing issues, such as healthcare and prescription coverage for all our patients, tort reform and continued advancement of our profession. n
Counterpoint
By Steven R. Feldman, M.D.
I question the underlying motivations for trying to regulate the practice of negotiating a discount on pathology services. Using inflammatory terminology (“fee-splitting”) does not enlighten the debate.
Consider the role of a general contractor in building your new home. The general contractor building the house hires a subcontractor to do some aspect of the work. The general contractor is responsible for making sure the proper service was performed, for coordinating this service with other services being provided, for assuring that a reputable subcontractor is used, for assuring the quality of the service the subcontractor provided, and, most importantly, for the time and trouble of interacting with you.
By providing that subcontractor work on a large number of homes, the general contractor is able to negotiate a discount on the price of the subcontractor’s service.
The general contractor will likely charge you more than the subcontractor charged the contractor, but had you tried getting the subcontractor to do a single small job yourself, you might find yourself paying the same charge the general contractor charged you. This is basic economics and nothing about it is unethical.
The Dermatologist as Contractor
It’s hard to find anything unethical about the analogous practice of a dermatologist or other front-line clinician negotiating a discount with a high-quality “subcontractor” pathologist, billing the patient the standard charge, and keeping the difference to cover the clinician’s cost of assuring quality control, coordination of care, billing and communicating with the patient concerning the pathology results.
When pathologists claim that the clinician is “gouging” the patient, they should carefully consider the fact that the dermatologist does not bill the patient any more than the allowable fee that the pathologist would charge if they were billing the patient directly. If anything, the patient is potentially getting value added from the dermatologist at no additional cost.
Why Regulate?
So, if there isn’t an ethical dilemma, then what accounts for the efforts to try to regulate dermatologists from serving as middlemen on dermatopathology services?
Some of the proposed regulations would prevent dermatologists from using pathology billing codes; this would not only stop indirect billing, it would also prevent dermatologists from providing the dermatopathology services themselves.
Indirect billing regulations even preclude negotiating discounts from pathologists and passing on savings to patients.
The arguments against indirect billing are for the most part unethical turf grabs, dressed in “ethical” and “quality” clothing.
Fee-splitting, or the act of receiving payment for referring a patient, has been a hotly debated topic in dermatology and in medicine in general. Specific to dermatology, a debate has grown over the ethics and legality of negotiating a discount on pathology services. If you have a pathologist or dermatopathologist review a patient’s slides, should you make money on a pathologist’s services? Or, are you simply referring the patient and should you, therefore, let the pathologist bill the patient directly? Two dermatologists take sides on this controversial issue.
Point
By Gary Goldenberg, M.D.
The Wall Street Journal (WSJ) recently ran a front-page article outlining a practice of fee-splitting, the term used to define the practice of physicians being paid for referring a patient to another physician or for a specific treatment. This practice is commonly used by dermatologists to increase profits and by pathologists to increase caseload and therefore, increase profit.1 Since the article emphasized this issue, a debate between pathologists, dermatologists and dermatopathologists has ensued.
The Journal of the American Academy of Dermatology recently published several editorials from some of the most well known and respected dermatologists and dermatopathologists in the field that outlined different points of view regarding this issue, as well as other related topics.2-5
I will review the above issues
and show the following:
1. Fee splitting is wrong, if not from the legal point of view (at least not in every state and not yet), certainly form an ethical point of view.
2. Dermatologists should be able to continue to “read out” their own slides, even if just on the “easy” cases.
3. Legal action should not be required in this case, since we should be able to police ourselves.
Why Fee-Splitting is Wrong
Let’s examine the following scenario. In “Small Town, USA” there is a large primary care group that refers its patients to two dermatology practices in town. What if one of the dermatology groups approached the primary care group with the following proposition: Send us all your dermatology cases for a per case flat fee and keep the insurance reimbursement difference as profit? (Of course, Medicare patients cannot be included in this deal since that would be illegal.)
Not only is there now financial incentive for the primary care group to refer all of its patients to the one dermatology practice, they will also directly profit from the labor of other physicians.
Aren’t there already enough malpractice attorneys who profit from our work? Also, will the other dermatology practice in this small town be able to survive?
I believe fee-splitting is morally wrong, not to mention that it may be in the grey area of the law. All billing is done by Medicare standards, so why not this? If Medicare continues to make fee-splitting illegal, it should also be illegal for all other insurance carriers.
Reading Our Own Slides
Now let’s tackle the issue of whether we should be able to read our own slides. The answer is yes, and here’s why.
First, some would argue that dermatologists do not have enough training to perform this task. This is simply not true. Feldman and colleagues showed that dermatology residents complete more hours of dermatopathology training than pathology residents and that there is more dermatopathology in dermatology literature than in pathology literature.6
In that case, if general pathologists are allowed to read out dermatology cases, so should dermatologists. Some have also argued that dermatologists only read out “easy” cases and send the more “difficult” cases to dermatopathologists for consultation. I argue that general pathologists do the same thing.
Should general pathologists not be allowed to read out dermatology cases? Are there enough board certified dermatopathologists to handle the growing load of skin biopsy specimens? The answer to both questions is probably no.
Focusing on Our Patients
Do we need more government or medical board regulations to tell us how to best treat our patients? The answer is a definite no. Furthermore, with 800,000 attorneys in this country, our legal system already provides enough disincentive for us not to perform any services with which we are uncomfortable. We also cannot forget to do what’s best for our patients. I am sure that most dermatology residents are very comfortable recognizing basal cell carcinomas, but I doubt that anyone would make a diagnosis of a melanoma without being a board certified dermatopathologist or consulting with a dermatopathologist.
Instead of focusing on differences of opinion, we need to concentrate on more pressing issues, such as healthcare and prescription coverage for all our patients, tort reform and continued advancement of our profession. n
Counterpoint
By Steven R. Feldman, M.D.
I question the underlying motivations for trying to regulate the practice of negotiating a discount on pathology services. Using inflammatory terminology (“fee-splitting”) does not enlighten the debate.
Consider the role of a general contractor in building your new home. The general contractor building the house hires a subcontractor to do some aspect of the work. The general contractor is responsible for making sure the proper service was performed, for coordinating this service with other services being provided, for assuring that a reputable subcontractor is used, for assuring the quality of the service the subcontractor provided, and, most importantly, for the time and trouble of interacting with you.
By providing that subcontractor work on a large number of homes, the general contractor is able to negotiate a discount on the price of the subcontractor’s service.
The general contractor will likely charge you more than the subcontractor charged the contractor, but had you tried getting the subcontractor to do a single small job yourself, you might find yourself paying the same charge the general contractor charged you. This is basic economics and nothing about it is unethical.
The Dermatologist as Contractor
It’s hard to find anything unethical about the analogous practice of a dermatologist or other front-line clinician negotiating a discount with a high-quality “subcontractor” pathologist, billing the patient the standard charge, and keeping the difference to cover the clinician’s cost of assuring quality control, coordination of care, billing and communicating with the patient concerning the pathology results.
When pathologists claim that the clinician is “gouging” the patient, they should carefully consider the fact that the dermatologist does not bill the patient any more than the allowable fee that the pathologist would charge if they were billing the patient directly. If anything, the patient is potentially getting value added from the dermatologist at no additional cost.
Why Regulate?
So, if there isn’t an ethical dilemma, then what accounts for the efforts to try to regulate dermatologists from serving as middlemen on dermatopathology services?
Some of the proposed regulations would prevent dermatologists from using pathology billing codes; this would not only stop indirect billing, it would also prevent dermatologists from providing the dermatopathology services themselves.
Indirect billing regulations even preclude negotiating discounts from pathologists and passing on savings to patients.
The arguments against indirect billing are for the most part unethical turf grabs, dressed in “ethical” and “quality” clothing.
Fee-splitting, or the act of receiving payment for referring a patient, has been a hotly debated topic in dermatology and in medicine in general. Specific to dermatology, a debate has grown over the ethics and legality of negotiating a discount on pathology services. If you have a pathologist or dermatopathologist review a patient’s slides, should you make money on a pathologist’s services? Or, are you simply referring the patient and should you, therefore, let the pathologist bill the patient directly? Two dermatologists take sides on this controversial issue.
Point
By Gary Goldenberg, M.D.
The Wall Street Journal (WSJ) recently ran a front-page article outlining a practice of fee-splitting, the term used to define the practice of physicians being paid for referring a patient to another physician or for a specific treatment. This practice is commonly used by dermatologists to increase profits and by pathologists to increase caseload and therefore, increase profit.1 Since the article emphasized this issue, a debate between pathologists, dermatologists and dermatopathologists has ensued.
The Journal of the American Academy of Dermatology recently published several editorials from some of the most well known and respected dermatologists and dermatopathologists in the field that outlined different points of view regarding this issue, as well as other related topics.2-5
I will review the above issues
and show the following:
1. Fee splitting is wrong, if not from the legal point of view (at least not in every state and not yet), certainly form an ethical point of view.
2. Dermatologists should be able to continue to “read out” their own slides, even if just on the “easy” cases.
3. Legal action should not be required in this case, since we should be able to police ourselves.
Why Fee-Splitting is Wrong
Let’s examine the following scenario. In “Small Town, USA” there is a large primary care group that refers its patients to two dermatology practices in town. What if one of the dermatology groups approached the primary care group with the following proposition: Send us all your dermatology cases for a per case flat fee and keep the insurance reimbursement difference as profit? (Of course, Medicare patients cannot be included in this deal since that would be illegal.)
Not only is there now financial incentive for the primary care group to refer all of its patients to the one dermatology practice, they will also directly profit from the labor of other physicians.
Aren’t there already enough malpractice attorneys who profit from our work? Also, will the other dermatology practice in this small town be able to survive?
I believe fee-splitting is morally wrong, not to mention that it may be in the grey area of the law. All billing is done by Medicare standards, so why not this? If Medicare continues to make fee-splitting illegal, it should also be illegal for all other insurance carriers.
Reading Our Own Slides
Now let’s tackle the issue of whether we should be able to read our own slides. The answer is yes, and here’s why.
First, some would argue that dermatologists do not have enough training to perform this task. This is simply not true. Feldman and colleagues showed that dermatology residents complete more hours of dermatopathology training than pathology residents and that there is more dermatopathology in dermatology literature than in pathology literature.6
In that case, if general pathologists are allowed to read out dermatology cases, so should dermatologists. Some have also argued that dermatologists only read out “easy” cases and send the more “difficult” cases to dermatopathologists for consultation. I argue that general pathologists do the same thing.
Should general pathologists not be allowed to read out dermatology cases? Are there enough board certified dermatopathologists to handle the growing load of skin biopsy specimens? The answer to both questions is probably no.
Focusing on Our Patients
Do we need more government or medical board regulations to tell us how to best treat our patients? The answer is a definite no. Furthermore, with 800,000 attorneys in this country, our legal system already provides enough disincentive for us not to perform any services with which we are uncomfortable. We also cannot forget to do what’s best for our patients. I am sure that most dermatology residents are very comfortable recognizing basal cell carcinomas, but I doubt that anyone would make a diagnosis of a melanoma without being a board certified dermatopathologist or consulting with a dermatopathologist.
Instead of focusing on differences of opinion, we need to concentrate on more pressing issues, such as healthcare and prescription coverage for all our patients, tort reform and continued advancement of our profession. n
Counterpoint
By Steven R. Feldman, M.D.
I question the underlying motivations for trying to regulate the practice of negotiating a discount on pathology services. Using inflammatory terminology (“fee-splitting”) does not enlighten the debate.
Consider the role of a general contractor in building your new home. The general contractor building the house hires a subcontractor to do some aspect of the work. The general contractor is responsible for making sure the proper service was performed, for coordinating this service with other services being provided, for assuring that a reputable subcontractor is used, for assuring the quality of the service the subcontractor provided, and, most importantly, for the time and trouble of interacting with you.
By providing that subcontractor work on a large number of homes, the general contractor is able to negotiate a discount on the price of the subcontractor’s service.
The general contractor will likely charge you more than the subcontractor charged the contractor, but had you tried getting the subcontractor to do a single small job yourself, you might find yourself paying the same charge the general contractor charged you. This is basic economics and nothing about it is unethical.
The Dermatologist as Contractor
It’s hard to find anything unethical about the analogous practice of a dermatologist or other front-line clinician negotiating a discount with a high-quality “subcontractor” pathologist, billing the patient the standard charge, and keeping the difference to cover the clinician’s cost of assuring quality control, coordination of care, billing and communicating with the patient concerning the pathology results.
When pathologists claim that the clinician is “gouging” the patient, they should carefully consider the fact that the dermatologist does not bill the patient any more than the allowable fee that the pathologist would charge if they were billing the patient directly. If anything, the patient is potentially getting value added from the dermatologist at no additional cost.
Why Regulate?
So, if there isn’t an ethical dilemma, then what accounts for the efforts to try to regulate dermatologists from serving as middlemen on dermatopathology services?
Some of the proposed regulations would prevent dermatologists from using pathology billing codes; this would not only stop indirect billing, it would also prevent dermatologists from providing the dermatopathology services themselves.
Indirect billing regulations even preclude negotiating discounts from pathologists and passing on savings to patients.
The arguments against indirect billing are for the most part unethical turf grabs, dressed in “ethical” and “quality” clothing.
